Provider Demographics
NPI:1174520688
Name:ELDERS, JOHN GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GREGORY
Last Name:ELDERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 BURNETT DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2941
Mailing Address - Country:US
Mailing Address - Phone:870-425-6971
Mailing Address - Fax:870-508-8900
Practice Address - Street 1:630 BURNETT DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2941
Practice Address - Country:US
Practice Address - Phone:870-425-6971
Practice Address - Fax:870-508-8900
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC7687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121500001Medicaid
AR080035552OtherRAILROAD MEDICARE
AR080035552OtherRAILROAD MEDICARE
ARE59227Medicare UPIN